Your Bupa membership guide - Bupa Select
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Your Bupa membership guide Bupa Select Essential information explaining your Bupa cover Please retain
About this guide
Welcome to your Bupa Select membership guide
At Bupa, we know that insurance can be hard to follow. That’s why we have made this
guide as simple as possible. You will find individual chapters that deal with each aspect
of your Bupa cover, including a step-by-step guide to making a claim.
Please make sure that you keep this guide somewhere safe. You will need it when you
come to claim.
If any of the terms or language used leave you confused – don’t worry, we have also
included a glossary featuring clear definitions of words that are in bold italic in the text.
If you require correspondence and marketing literature in an alternative format, we offer
a choice of Braille, large print or audio. Please get in touch to let us know which you
would prefer.
For those with hearing or speech difficulties we use Relay UK which offers support for
individuals who are deaf, hard-of-hearing, or speech-impaired. Relay UK allows for both
smartphone and textphone communication:
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if you are using a smartphone, please download the Relay UK app and follow the
steps outlined by the app. Then when you wish to make an outbound call just use the
prefix 18001 followed by your Bupa helpline number and you’ll be connected, or
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if you are contacting us on a textphone please use the prefix 18001 followed by your
Bupa helpline number.
To update your preferred contact method to Relay UK, please let one of our
advisers know.
How do I know what I’m covered for?
The precise details of the cover you have chosen are listed on your membership
certificate. Please read this membership guide together with your membership
certificate, as together they set out full details of how your health insurance works.
How does the membership guide work with my membership certificate?
Your membership certificate explains the benefits available to you and also provides
the benefit note numbers that correspond to the benefit notes in the ‘Benefits’ section
of the membership guide (where you will find a more detailed explanation of the
benefits in your individual policy).
Page 2How do I contact Bupa?
We are always on hand to help.
For queries about your cover we have provided a dedicated number which you will
find on your membership certificate.
You can also write to us at Bupa, Bupa Place, 102 The Quays, Salford M50 3SP
Bupa Anytime HealthLine^
If you have any questions or worries about your health call our confidential Bupa
Anytime HealthLine on 0345 607 7777*. Our qualified nursing team is on hand 24 hours
a day, so whatever your health question or concern, they have the skills and practical,
professional experience to help.
Family Mental HealthLine^
If you are a parent or care for a young person, and have concerns about their mental
wellbeing, our Family Mental HealthLine is available to provide advice, guidance and
support. A trained adviser and/or mental health nurse will listen to what your family is
experiencing and give you advice about what to do next.
Call our Family Mental HealthLine on 0345 266 7938†*. The young person does not have
to be covered under your policy for you to be able to use this service.
^Bupa Anytime HealthLine and Family Mental Healthline are not regulated by the Financial Conduct Authority
or the Prudential Regulation Authority.
†Telephone support between 8am to 6pm Monday to Friday.
*Calls may be recorded and to maintain the quality of our service a nursing manager may monitor some calls
always respecting the confidentiality of the call.
Page 3Contents at a glance Your rules and benefits 5 How your membership works 6 The agreement between the sponsor and us 6 The documents that set out your cover 6 Payment of benefits 6 When your membership starts, renews and ends 7 Making changes 9 General information 9 Private Healthcare Information Network 9 Making a complaint 9 Contributing members 11 Claiming 13 Step-by-step guide to making a claim 13 A Information on claiming 16 B How we will deal with your claim 19 C If you want to withdraw a claim 21 D Treatment costs outside the terms of your cover 21 E If you have an excess or co-insurance 21 Benefits 24 Notes on benefits 24 What you are covered for 27 Cash benefits 43 What is not covered 47 Glossary 59 Privacy notice – in brief 69 Financial crime and sanctions 71 Page 4
Your rules and benefits
Effective from 1 January 2021
These are the rules and benefits of Bupa Select
They apply to members of the scheme whose ‘Group contract start date’, as stated in
the Group details section of their membership certificate, is on or after the ‘Effective
from’ date.
Words and phrases in bold italic in this membership guide are defined terms which have
a specific meaning. You should check their meaning in the glossary.
Important note
Please read this note before you read the rest of this membership guide as it
explains how this membership guide and your membership certificate work together.
This Bupa Select membership guide and your membership certificate together set
out full details of your benefits. They should not be read as separate documents.
This membership guide is a generic guide. It contains the general membership terms
that apply to all Bupa Select members. It also contains all the elements of cover
that can be provided under Bupa Select. You may not have all the cover set out in
this membership guide. It is your membership certificate that shows the cover that
is specific to your benefits. Any elements of cover in this membership guide that
are either:
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shown on your membership certificate as ‘not covered’, or
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do not appear on your membership certificate
you are not covered for, and you should therefore ignore them when reading this
membership guide.
The ‘Further details’ section of your membership certificate: Your membership
certificate could also show some changes to the terms of cover set out in this
membership guide particularly in the ‘Further details’ section.
When reading this membership guide and your membership certificate, it is your
membership certificate which is personal to you. This means that if your membership
certificate contradicts this membership guide it is your membership certificate that
will take priority.
Always call the helpline if you are unsure of your cover.
Your rules and benefits Page 5How your membership works
The agreement between the sponsor and us
Your cover is provided under a group insurance policy governed by the agreement and
the terms and conditions of your membership have been agreed between your sponsor
and Bupa. There is no legal contract between you and us for your cover under the
agreement. Only the sponsor and Bupa have legal rights under the agreement. However:
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if you are a contributing member you will have legal rights as set out in this
membership guide. Please see the section ‘Contributing members’
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if you are not a contributing member we allow you access to the claims and
complaints processes as set out in this membership guide.
The documents that set out your cover
The following documents set out the details of the cover we will provide for you under
the agreement. These documents must be read together as a whole, they should not
be read as separate documents.
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The Bupa Select membership guide: this sets out the general terms and conditions
of membership (including exclusions) and all the elements of cover that can be
provided under Bupa Select.
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Your membership certificate: this shows the cover that is specific to your benefits,
including the underwriting method applied, the limits that apply, any variations to
the benefits, terms or conditions explained in this membership guide and whether
an excess or co-insurance applies to your cover and if it does, the amount and how
it applies.
Payment of benefits
We only pay benefits for treatment you receive while you are covered under the
agreement and we only pay benefits in accordance with the cover that applies to you on
the date the treatment takes place. We do not pay for any treatment, including any
treatment we have pre-authorised, that takes place on or after the date your cover ends.
When you receive private medical treatment you have a contract with the providers of
your treatment. You are responsible for the costs you incur in having private treatment.
However, if your treatment is eligible treatment we pay the costs that are covered under
your benefits. Any costs, including eligible treatment costs, that are not covered under
your benefits are your sole responsibility. The provider might, for example, be a
consultant, a recognised facility or both. Sometimes one provider may have arrangements
with other providers involved in your care and, therefore, be entitled to receive all the
costs associated with your treatment. For example a recognised facility may charge for
recognised facility charges, consultants’ fees and diagnostic tests all together.
Page 6 How your membership worksOther than in relation to the reimbursement of eligible treatment costs, there is no
contract between you and us in respect of any private medical treatment or any other
clinical services that you receive under your policy. We are not the provider of these
things and this means that we are not responsible for the delivery of your private
medical treatment or other clinical services.
In many cases we have arrangements with providers about how much they charge our
members for treatment and how we pay them. For treatment costs covered under your
benefits we will, in most cases, pay the provider of your treatment direct – such as the
recognised facility or consultant – or whichever other person or facility is entitled to
receive the payment. Otherwise we will pay the main member. We will write to the
main member or dependant having treatment (when aged 16 and over) when there is
an amount for them to pay in relation to any claim (for example if they have an excess
amount to pay) and who payment should be made to.
Please also see the section ‘Claiming’.
When your membership starts, renews and ends
Starting membership
Your membership under the agreement must be confirmed by the sponsor.
Your cover starts on your cover start date.
Your dependants’ cover starts on their cover start date. Your cover start date and your
dependants’ cover start date(s) may not be the same.
Cover for a newborn baby
If the sponsor agrees, you may apply to include your newborn baby under your
membership as one of your dependants. If your baby’s membership would be as:
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an underwritten member, we will not apply any special conditions to the baby’s cover
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a moratorium member, we will not apply the exclusion for moratorium conditions to
the baby’s cover – see Exclusion 33 in the section ‘What is not covered’
but only if both the following apply:
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you and/or your partner have been covered under the scheme (and if applicable
a previous scheme) for at least 12 continuous months before the baby’s birth and
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you include your baby under your membership within three months of the baby’s birth.
In which case if we agree to cover your baby it will be from their date of birth or your
cover start date if their date of birth is before your cover start date.
Renewal of your membership
The renewal of your membership is subject to the sponsor renewing your membership
under the agreement.
If you are a contributing member please see the section ‘Contributing members’.
How membership can end
You or the sponsor can end your membership or the membership of any of your
dependants at any time.
How your membership works Page 7If you want to end your membership or that of any of your dependants you must write
to us. If your membership ends the membership of all your dependants will also end.
If you are a contributing member please see the section ‘Contributing members’.
Your membership and that of your dependants will automatically end if:
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the agreement is terminated
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the terms of the agreement say that it must end
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the sponsor does not pay subscriptions or any other payment due under the
agreement for you or any other person. If you are a contributing member please
see the section ‘Contributing members’.
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you stop living in the UK (you must inform us if you stop living in the UK), or
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you die.
Your dependants’ membership will automatically end if:
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your membership ends
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the terms of the agreement say that it must end
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the sponsor does not renew the membership of that dependant
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that dependant stops living in the UK (you must inform us if that dependant stops
living in the UK), or
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that dependant dies.
If there is reasonable evidence that you or a dependant did not take reasonable care in
answering our questions (by this we mean giving false information or keeping necessary
information from us) then if this was:
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intentional, we may treat your or (if applicable) your dependant’s cover as if it never
existed and refuse to pay all claims
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careless, then depending on what we would have done if you or they had answered
our questions correctly, we may treat your or (if applicable) your dependant’s cover
as if it never existed and refuse to pay all claims (in which case you may need to repay
any claims we have paid and if you are a contributing member we will return to the
sponsor any subscriptions you have paid in respect of your or (if applicable) your
dependant’s cover), change your or their cover, or we could reduce any claim payment.
When your membership or your dependants’ membership ends, we may be able to offer
you or them continuation of membership on a Bupa personal policy as an ex-group scheme
member depending upon how long you or they have been a Bupa group scheme member.
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If you or they are an underwritten member this would allow you or them to transfer
without any additional special conditions
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If you or they are a moratorium member this would allow you or them to transfer
without a change to the moratorium start date that applies to you or them under the
Bupa group scheme
but only if, in each case, you or they transfer within three months of the date your or
their cover under the Bupa group scheme ends without any break in your or their cover.
If you would like to consider this option please call 0800 600 500 to discuss it with us.
We may record or monitor our calls.
Paying subscriptions and other charges
The sponsor must pay to us subscriptions and any other payment due for your
membership and that of every other person covered under the agreement. Bupa
Page 8 How your membership worksInsurance Services Limited acts as our agent for arranging and administering your policy.
Subscriptions are collected by Bupa Insurance Services Limited as our agent for the
purpose of receiving, holding and refunding premiums and claims monies.
If you are a contributing member please see the section ‘Contributing members’.
Making changes
Changes to your membership
The terms and conditions of your membership, including your benefits, may be changed
from time to time by agreement between the sponsor and us.
No other person is allowed to make or confirm any changes to your membership or your
benefits on our behalf or decide not to enforce any of our rights. Equally, no change to
your membership or your benefits will be valid unless it is specifically agreed between
the sponsor and us and confirmed in writing.
If you are a contributing member please see the section ‘Contributing members’.
General information
Change of address
You should call or write to tell us if you change your address.
Correspondence and documents
All membership documents are sent to the main member.
All claims correspondence is sent to the main member, or to the dependant having the
treatment when they are aged 16 and over.
When you send documents to us, we cannot return original documents to you. However,
we will send you copies if you ask us to do so at the time you give us the documents.
Letters between us must be sent with the postage costs paid before posting. We can
each assume that the letter will be received three days after posting.
Applicable law
The agreement is governed by English law.
Private Healthcare Information Network
You can find independent information about the quality and cost of private treatment
available from doctors and hospitals from the Private Healthcare Information Network:
www.phin.org.uk
Making a complaint
We are committed to providing you with a first class service at all times and will make
every effort to meet the high standards we have set. If you feel that we have not
achieved the standard of service you would expect or if you are unhappy in any other
way, then please get in touch.
How your membership works Page 9If you need help or support or have any comments or complaints, please call your dedicated Bupa helpline number on your membership certificate. Alternatively, you can contact us: In writing: Customer Relations, Bupa, Bupa Place, 102 The Quays, Salford M50 3SP By email: customerrelations@bupa.com Please be aware that information you send to this email address may not be secure unless you send us your email through Egress. For more information and to sign up for a free Egress account, go to https://switch.egress.com. You will not be charged for sending secure emails to a Bupa email address using the Egress service. How will we deal with your complaint and how long is this likely to take? If we can resolve your complaint within three working days after the day you made your complaint, we will write to you to confirm this. Where we are unable to resolve your complaint within this time, we will promptly write to you to acknowledge receipt. We will then continue to investigate your complaint and aim to send you our final written decision within four weeks from the day of receipt. If we are unable to resolve your complaint within four weeks following receipt, we will write to you to confirm that we are still investigating it. Within eight weeks of receiving your complaint we will either send you a final written decision explaining the results of our investigation or we will send you a letter advising that we have been unable to reach a decision at this time. If you remain unhappy with our response, or after eight weeks you do not wish to wait for us to complete our review, you may refer your complaint to the Financial Ombudsman Service. You can write to them at: Exchange Tower, London E14 9SR or contact them via email at complaint.info@financial-ombudsman.org.uk or call them on 0800 023 4567 (calls to this number are free on mobile phones and landlines) or 0300 123 9123 (calls to this number cost no more than calls to 01 and 02 numbers). For more information you can visit www.financial-ombudsman.org.uk If you refer your complaint to the Financial Ombudsman Service, they will ask for your permission to access information about you and your complaint. We will only give them what’s necessary to investigate your complaint and this may include medical information. If you are concerned about this, please contact us. Your complaint will be dealt with confidentially and will not affect how we treat you in the future. Following the complaints procedure does not affect your right to take legal action. The European Commission also provides an online dispute resolution (ODR) platform which allows consumers who purchase online to submit complaints through a central site which forwards the complaint to the relevant Alternative Dispute Resolution (ADR) scheme. For Bupa, complaints will be forwarded to the Financial Ombudsman Service and you can refer complaints directly to them using the details above. For more information about ODR please visit http://ec.europa.eu/consumers/odr Page 10 How your membership works
The Financial Services Compensation Scheme (FSCS)
In the unlikely event that we cannot meet our financial obligations, you may be entitled
to compensation from the Financial Services Compensation Scheme. This will depend
on the type of business and the circumstances of your claim.
The FSCS may arrange to transfer your policy to another insurer, provide a new policy
or, where appropriate, provide compensation. Further information about compensation
scheme arrangements is available from the FSCS on 0800 678 1100 or 020 7741 4100
or on its website at: www.fscs.org.uk
Contributing members
This section only applies to contributing members.
The sponsor must pay to us subscriptions and any other payment due for your
membership, and that of your dependants and every other person covered under the
agreement. You contributing to the cost of subscriptions for you and/or any of your
dependants does not in any way affect the contractual position set out in the section
‘The agreement between the sponsor and us’.
Contributions paid by you to the subscriptions the sponsor has paid for you (eg by payroll
deduction) will be deemed to have been received by Bupa once they are received by
your sponsor.
As soon as reasonably practicable you will be provided with the terms and conditions
that will apply to your cover, and the sponsor will notify you of the contribution you
will need to make to the cost of subscriptions from the cover start date for the next
membership year.
If you do not want your cover (and therefore the cover for your dependants) or the
individual cover for any of your dependants to renew at the renewal date you can notify
your sponsor at any time in advance of the renewal date.
If you wish to end your membership (and therefore that of your dependants) the
following terms apply:
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You may end your membership (and therefore the membership of your dependants)
by informing the sponsor within 21 days of either:
– the date you receive your terms and conditions (including your membership
certificate) confirming your cover, or
– your cover start date
whichever is the later. During this 21 day period if you have not made any claims we
will refund to the sponsor all of the subscriptions the sponsor has paid for you for
that year.
After this 21 day period you can end your membership (and therefore the membership
of all your dependants) by informing the sponsor at any time during the year. In which
case we will refund to the sponsor any subscriptions the sponsor has paid for you that
relate to the period after your membership ends.
How your membership works Page 11J
You may end the membership of any dependant by informing the sponsor within
21 days of either:
– the date you receive your terms and conditions (including your membership
certificate) confirming the cover for that dependant, or
– the cover start date for that dependant
whichever is the later. During this 21 day period if no claims have been made in
respect of that dependant we will refund to the sponsor all of the subscriptions the
sponsor has paid for you that relate to that dependant for that year.
After this 21 day period you can cancel a dependant’s membership by informing the
sponsor at any time during the year. In which case we will refund to the sponsor any
subscriptions the sponsor has paid for you in respect of that dependant for the
period after their membership ends.
Your membership and that of your dependants will automatically end if the sponsor
does not pay subscriptions or any other payment due under the agreement for you or
any other person, however, we will continue to pay eligible claims for you and/or your
dependant for the period for which you can provide evidence (eg on payslips) that you
paid contributions to subscriptions to the sponsor.
Where we have refunded to the sponsor subscriptions paid for you or your dependants,
you should contact the sponsor in order to obtain a refund of the contributions you
made to those refunded subscriptions.
Changes to your membership
If:
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any changes to the terms and conditions of your membership, including your
benefits, are agreed between the sponsor and us, or
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we change the procedure for making a claim
you will be informed before the change takes effect. If you do not accept any of the
changes you can end your membership by informing the sponsor either:
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within 28 days of the date on which the change takes effect, or
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within 28 days of you being told about the change
whichever is later.
Demands and needs statement
The cover provided under membership of the scheme is generally suitable for someone
who is looking to cover the cost of a range of health expenses. We have not provided
you with any advice about your cover and how it meets your individual needs. Please
read your membership certificate and this membership guide to make sure that the
cover meets your needs.
Page 12 How your membership worksClaiming
Step-by-step guide to making a claim
Being referred for treatment
Your consultation or treatment must follow an initial referral by:
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our Direct Access service, if you have cover for it as explained in ‘Step 1 Find out if the
Direct Access service is available to you’
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a GP (including via a digital GP service), or
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another healthcare practitioner. The situations in which we will accept such a referral
are set out on bupa.co.uk/referrals
Step 1 Find out if the Direct Access service is available to you
For certain medical conditions you can call us directly for a referral to a
consultant, therapist or mental health and wellbeing therapist usually without
seeing your GP and we call this our Direct Access service. For details about
cover for Direct Access and how it works please see the Benefits section in
this guide under the heading ‘Direct Access service’ and the ‘Further details’
section of your membership certificate.
Step 2 If Direct Access is not available (or if you prefer) – consult a GP for
an open referral
Sometimes, when you have had a consultation with another healthcare
practitioner before consulting a GP and they believe referral to a consultant is
appropriate, a GP appointment may not be clinically necessary. The situations
in which we will accept such a referral are set out on bupa.co.uk/referrals or
you can call us.
Consult a GP, they will assess if you need to see a consultant. If they decide
that you do, ask them for an ‘open referral’ (unless a paediatric referral is
required – see ‘Information about cover for children’ in this Step 2). This allows
us to offer you a choice of nearby recognised practitioners including
consultants covered under your policy.
Check within the Group Details section of your membership certificate to
see if the Open Referral service applies to your benefits.
If the Open Referral service does not apply to your benefits: Some GPs may
prefer to give a ‘named referral’ to a certain consultant, however you should
call us before you make an appointment to confirm that we recognise them
under your benefits, to avoid your being liable to pay.
When you call us we will:
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help you find a fee-assured consultant or recognised practitioner within
your local area covered under your benefits, and
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confirm the benefits available to you under your cover.
Claiming Page 13If the Open Referral service does apply to your benefits
You must:
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obtain an open referral from a GP to ensure that your treatment is covered,
and to avoid having to return to a GP to get an open referral; then
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call us to pre-authorise any claim before arranging or receiving any
treatment. When you call we will:
– help you find a fee-assured consultant in our list of Open Referral
Network consultants that applies to your benefits
– help you find a recognised practitioner within your local area
– confirm the benefits available to you under your cover.
Important note
Failure to obtain pre-authorisation from us means that you will be responsible
for paying for all such treatment if we would not have pre-authorised
that treatment.
Information about cover for children aged 17 or under
It is not always possible for us to find you a paediatric consultant so when
a paediatric referral is required we ask that you obtain a named referral
from a GP.
Some private hospitals do not provide services for children or have restricted
services available for children, so treatment may be offered at an NHS
hospital. You can ask us about recognised facilities where paediatric services
are available or you can find them on finder.bupa.co.uk
Where in-patient or day-patient eligible treatment is required, children are
likely to be treated in a general children’s ward. This is in line with good
paediatric practice.
Step 3 Call us
Simply call the number on your membership certificate and we will talk you
through your options. We will explain which nearby consultants, facilities
and healthcare professionals are covered under your Bupa membership and
provide you with a pre-authorisation number so your healthcare provider
can send the bill directly to us.
If your consultant recommends further tests or treatment, it is important you
check back with us to obtain further pre-authorisation.
Page 14 ClaimingThe ‘Six-week scheme’
The benefit table on your membership certificate shows whether this ‘Six-week scheme’
applies to you. If it applies to you, we do not pay for any treatment (including diagnostic
procedures) that are to be carried out as a day-patient or in-patient if it is available under
the NHS within six weeks of the date on which your consultant tells you that you need
that treatment.
How it works
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If the NHS can offer you the treatment you need (including diagnostic procedures)
as a day-patient or in-patient within six weeks of the date on which your consultant
tells you that you need that treatment, we will not pay for your treatment privately.
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If the NHS cannot offer the treatment you need within those six weeks,
we will pay for your eligible treatment privately.
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Each time you need eligible treatment as a day-patient or in-patient your
consultant must confirm to us whether there is a wait of more than six weeks for
you to have that treatment through the NHS.
Under Benefit CB1 we do not pay cash benefit for NHS in-patient treatment if the
treatment you need is available under the NHS within this six-week period.
For example:
Jack is told on 1 July by his consultant that he needs to have an operation and finds that
the NHS cannot perform the operation until 30 October at the earliest. As this timescale
is outside the six-week period, and it is for eligible treatment, Jack can have his
operation privately.
If the NHS had been able to schedule Jack’s operation before 12 August, under the
Six-week scheme, he would have been treated by the NHS.
Claims checklist
What you will need to make a claim – to help us to make the claims process as simple
and swift as possible, please have the following information close to hand when you
call to make a claim:
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your Bupa membership number
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details of the condition you are suffering from
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details of when your symptoms first began
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details of when you first consulted a GP about your condition
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details of the treatment that has been recommended
Claiming Page 15A Information on claiming
A1 Claims other than Cash benefits
Bupa Health Check – if you have cover for it under benefit 1.7
Step one
Call your helpline to ask for a pre-authorisation number within 45 days of the date you
would like your health check to take place. You will find your helpline number on your
membership certificate.
Step two
You will be transferred to our booking team to arrange your appointment. Give the
adviser your pre-authorisation number and postcode. They will tell you which Bupa
Health Centres are located nearby, for you to choose a place and time to suit you.
Step three
Your Bupa Health Check is booked. We will send you a confirmation email with all the
information you will need. There is no need to fill in a claim form as the Bupa Health
Centre will invoice us direct.
If you are a moratorium member
As a moratorium member you are not covered for treatment of any moratorium
conditions. Each time you make a claim you must provide us with information so
we can confirm whether your proposed treatment is covered under your benefits.
Before you arrange any consultation or treatment call us and we will send you
a pre-treatment form to complete. You will need to provide details of the history of
the medical condition you are claiming for, including information that you will need
to ask your GP or consultant for.
Your GP or consultant may charge you a fee for providing a report which we do not pay.
Each claim you make while you are a moratorium member will be assessed on this
information and any further information we ask you to provide to us at the time you claim.
Once we receive all the information we ask you for we will:
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confirm whether your proposed treatment will be eligible under your benefits and,
if so, the medical providers or treatment facilities available to you
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confirm the level of benefits available to you, and
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tell you whether you will need to complete a claim form.
If you do not need to complete a claim form we will treat your submission of your
pre-treatment form to us as your claim once we are notified that you have received your
consultation or treatment. In most cases we will be notified that you have received your
consultation or treatment by your consultant or the provider of your treatment.
If you do need to complete a claim form you will need to return the fully completed
pre-treatment form to us as soon as possible and in any event within six months of
receiving the treatment for which you are claiming unless this was not reasonably possible.
Page 16 ClaimingIf you are not a moratorium member
When you call us we will:
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confirm whether your proposed treatment will be eligible under your benefits and,
if so, the medical providers or treatment facilities available to you
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confirm the level of benefits available to you, and
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tell you whether you will need to complete a claim form.
If you do not need to complete a claim form, we will treat your call to us as your claim
once we are notified that you have received your consultation or treatment. In most
cases we will be notified that you have received your consultation or treatment by your
consultant or the provider of your treatment.
If you do need to complete a claim form you will need to return the fully completed
claim form to us as soon as possible and in any event within six months of receiving the
treatment for which you are claiming unless this was not reasonably possible.
Case management
If we believe you are having eligible treatment that could benefit from our case
management support we will provide a case manager to help you navigate through your
healthcare experience. Your case manager will contact you by phone and will work with
you to understand your individual needs and the best way to help you. This can include
discussing options available to you, liaising with healthcare professionals and helping you
get the most from your policy.
A2 Claims for Cash benefits
For benefits CB1 NHS cash benefit for NHS hospital in-patient treatment
and CB6 NHS cash benefit for treatment for cancer
If you are a moratorium member
Call the helpline and we will send you a form to complete. You will need to provide
details of the history of the medical condition you are claiming for, including information
that you will need to ask your GP or consultant for. Your GP or consultant may charge
you a fee for providing a report which we do not pay. Each claim you make while you are
a moratorium member will be assessed on this information and any further information
we ask you to provide to us at the time you claim.
Once we receive all the information we ask you for we will:
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confirm whether your treatment will be eligible for NHS cash benefit
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confirm the level of benefits available to you, and
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if required, send you a claim form which you will need to take with you to the hospital
and ask them to complete the hospital sections. You will need to return your fully
completed form to us as soon as possible and in any event within six months of
receiving your treatment unless this was not reasonably possible.
If you are not a moratorium member
Call the helpline to check whether your treatment will be eligible for NHS cash benefit.
We will confirm your benefits and, if required, send you a claim form which you will need
to take with you to the hospital and ask them to complete the hospital sections. You will
need to return your fully completed form to us as soon as possible and in any event
within six months of receiving your treatment unless this was not reasonably possible.
Claiming Page 17For benefits CB2 to CB5
Call the helpline to check your benefits. We will confirm your benefits and tell you
whether you need to complete a claim form. You must send us either:
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your completed claim form if you need to complete one – in which case you will need
to return your fully completed form to us as soon as possible and in any event within
six months of receiving your treatment unless this was not reasonably possible
or
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if you do not need a claim form, a covering letter giving your name, address and
membership number together with:
– for Family cash benefit: a copy of your child’s birth or adoption certificate
– for other cash benefits: your original invoices and receipts.
A3 Claims for repatriation and evacuation assistance
You must contact us before any arrangements are made for your repatriation or
evacuation. When you contact us we will check your cover and explain the process
for arranging repatriation or evacuation and making a claim. From inside or outside
the UK please contact us using your dedicated helpline. When your helpline is closed
call us on: +44 (0)131 588 0542. Lines open 24 hours 365 days a year. We may record
or monitor our calls.
A4 Treatment needed because of someone else’s fault
When you claim for treatment you need because of an injury or medical condition that
was caused by or was the fault of someone else (a ‘third party’), for example an injury
suffered in a road accident in which you are a victim, all of the following conditions apply
when you make such a claim:
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you agree you are responsible for the payment of any costs which may ultimately be
recovered from the third party
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you must notify us as soon as possible that your treatment was needed as a result of
a third party. You can notify us either by writing to us or completing the appropriate
section on your claim form. You must provide us with any further details that we
reasonably ask you for
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you must take any reasonable steps we ask of you to recover from the third party the
cost of the treatment paid for by us and claim interest if you are entitled to do so
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you (or your solicitor) must keep us fully informed in writing of the progress and
outcome of your claim
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if you recover the cost of any treatment paid for by us, you must repay the amount
and any interest to us.
A5 Other insurance cover
You can only claim for eligible private medical costs once. This means that if you have
two policies that provide private medical cover, the costs of your treatment may be split
between Bupa and the other insurance company. You will be asked to provide us with
full details of any other relevant insurance policy at the time of claim.
Page 18 ClaimingB How we will deal with your claim
B1 General information
When we have determined that your treatment is eligible treatment, we will discuss your
claim with you and issue you with a ‘pre-authorisation number’ confirming the treatment
is eligible under your current cover.
You can then contact your consultant or healthcare professional to arrange an
appointment. We recommend that you give them your ‘pre-authorisation number’ so the
invoice for your treatment costs can be sent to us direct.
Please note: If your cover ends for any reason we will not pay for any treatment that takes
place on or after the date your cover ends – even if we have pre-authorised the treatment.
Except for NHS cash benefit and Family cash benefit, we only pay eligible costs and
expenses actually incurred by you for treatment you receive.
We do not have to pay a claim if you or a dependant break any of the terms and
conditions of your or their membership, which are related to the claim. If there is
reasonable evidence that you or a dependant did not take reasonable care in answering
our questions (by this we mean giving false information or keeping necessary information
from us) then if this was:
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intentional, we may treat your or (if applicable) your dependant’s cover as if it never
existed and refuse to pay all claims
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careless, then depending on what we would have done if you or they had answered
our questions correctly, we may treat your or (if applicable) your dependant’s cover
as if it never existed and refuse to pay all claims (in which case you may need to repay
any claims we have paid and if you are a contributing member we will return to the
sponsor any subscriptions you have paid in respect of your or (if applicable) your
dependant’s cover), change your or their cover, or we could reduce any claim payment.
Unless we tell you otherwise, your claim form and proof to support your claim must be
sent to us.
We reserve the right to change the procedure for making a claim. If so, we will write and
tell the sponsor about any changes. If you are a contributing member please see the
section ‘Contributing members’.
B2 Providing us with information
You will need to provide us with information to help us assess your claim if we make
a reasonable request for you to do so. For example, we may ask you for one or more of
the following:
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medical reports and other information about the treatment for which you are claiming
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the results of any independent medical examination which we may ask you to
undergo at our expense
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original accounts and invoices in connection with your claim (including any related to
treatment costs covered by your excess or co-insurance – if any). We cannot accept
photocopies of accounts or invoices or originals that have had alterations made
to them.
If you do not provide us with any information we reasonably ask you for, we will be
unable to assess your claim.
Claiming Page 19Medical reports – when we need more information from your doctor
When we need to ask your doctor for more information, in writing about your
consultation, tests or treatment for insurance purposes, we will need your permission.
The Access to Medical Reports Act 1988 or the Access to Personal Files and Medical
Reports (NI) Order 1991 give you certain rights, which are:
1. You can give permission for your doctor to send us a medical report without asking
to see it before they send it to us.
2. You can give permission for your doctor to send us a medical report and ask to see
it before they send it to us.
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You will have 21 days from the date we ask your doctor for your medical report
to contact them and arrange to see it.
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If you don’t contact your doctor within 21 days we will ask them to send the
report straight to us.
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You can ask your doctor to change the report if you think it’s inaccurate or
misleading. If they refuse, you can insist on adding your own comments to the
report before they send it to us.
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Once you’ve seen the report, it won’t be sent to us unless you give your doctor
permission to do so.
3. You can withhold your permission for your doctor to send us a medical report. If you
do, we will be unable to see whether the consultation, test or treatment is covered by
your policy, and we won’t be able to give you a pre-authorisation number or confirm
whether we can contribute to the costs.
In any event you also have the right to ask your doctor to let you see a copy of your
medical report within six months of it being sent to us.
Your doctor can withhold some or all the information in the report if, in their view,
the information:
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might cause physical or mental harm to you or someone else or
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would reveal someone else’s identity without their permission (unless the person
is a healthcare professional and the information is about your care provided by
that person)
We may be able to pay towards the cost of a medical report. We will let you know when
we ask for your permission to request the report from your doctor. If we can pay towards
it, you will need to pay any remaining amount.
B3 How we pay your claim
Claims other than Cash benefits: for treatment costs covered under your benefits we
will, in most cases, pay the provider of your treatment direct – such as the recognised
facility or consultant – or whichever other person or facility is entitled to receive the
payment. Otherwise we will pay the main member. We will write to the main member or
dependant having treatment (when aged 16 and over) when there is an amount for them
to pay in relation to any claim (for example if they have an excess amount to pay) and
who the payment should be made to (for example their consultant or treatment facility).
Claims for cash benefits: we pay eligible claims to the main member.
Page 20 ClaimingClaims for overseas emergency treatment under benefit 9: we only pay eligible claims
in £sterling. When we have to make a conversion from a foreign currency to £sterling
we will use the exchange rate published in the UK’s Financial Times on the Monday of
the week in which the first day of your treatment takes place.
C If you want to withdraw a claim
If, for any reason, you wish to withdraw your claim for the costs of treatment you have
received, you should call the helpline to tell us as soon as possible. You will be unable to
withdraw your claim if we have already paid your claim.
If you do withdraw your claim you will be responsible for paying the costs of
that treatment.
D Treatment costs outside the terms of your cover
When you receive private medical treatment you have a contract with the providers of
your treatment. You are responsible for paying any costs that are not covered under
your benefits.
E If you have an excess or co-insurance
The sponsor may have agreed with us that either an excess or co-insurance shall apply
to your benefits. Your membership certificate shows if one does apply and if so,
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the amount
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who it applies to
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what type of treatment it is applied to, and
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the period for which the excess or co-insurance will apply.
Some further details of how an excess or co-insurance works are set out below and
should be read together with your membership certificate.
If you are unsure:
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whether an excess or co-insurance does apply to you, or
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how your excess or co-insurance works
please refer to your membership certificate or contact the helpline.
E1 How an excess or co-insurance works
Having an excess or co-insurance means that you have to pay part of any eligible
treatment costs that would otherwise be paid by us up to the amount of your excess or
co-insurance. By eligible treatment costs we mean costs that would have been payable
under your benefits if you had not had an excess or co-insurance.
If your excess or co-insurance applies each year it starts at the beginning of each year
even if your treatment is ongoing. So, your excess or co-insurance could apply twice to
a single course of treatment if your treatment begins in one year and continues into the
next year.
Claiming Page 21We will write to the main member or dependant having treatment (when aged 16
and over) to tell them who to pay their excess or co-insurance to, for example, their
consultant, therapist or treatment facility. The excess or co-insurance must be paid
direct to them – not to Bupa.
You should always make a claim for eligible treatment costs even if we will not pay
the claim because of your excess or co-insurance. Otherwise the amount will not be
counted towards your excess or co-insurance and you may lose out should you need
to claim again.
E2 How the excess or co-insurance applies to your benefits
Unless we say otherwise on your membership certificate:
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we apply the excess or co-insurance to your claims in the order in which we process
those claims
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when you claim for eligible treatment costs under a benefit that has a benefit limit
your excess or co-insurance amount will count towards your total benefit limit for
that benefit
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the excess or co-insurance does not apply to Cash benefits.
Excess and co-insurance examples
The following are examples only. You should check your membership certificate to see
how your excess or co-insurance applies to you and your benefits.
Example of how an annual fixed excess works: this is an example only and assumes that
all costs are eligible treatment costs and:
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an excess of £50 a year
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an out-patient benefit limit of £500 a year.
Example Excess
Out-patient benefit limit for the year £500
You incur costs for out-patient physiotherapy £250
We pay your therapist £200
We notify you of excess amount you pay direct to your therapist £50
Your remaining out-patient benefit limit for the rest of the year £250
Your remaining excess for the rest of the year £0
Page 22 ClaimingExample of how a rolling excess works: this is an example only and assumes that all
costs are eligible treatment costs and:
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a rolling excess of £100 in any 12 month period
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an out-patient benefit limit of £500 a year
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that you join the scheme on 1 January 2021.
Example Excess
Out-patient benefit limit for the year £500
On 1 March 2021 you incur costs for out-patient physiotherapy £150
We pay your therapist £50
We notify you of excess amount you pay direct to your therapist £100
Your remaining out-patient benefit limit for the rest of the year £350
Your remaining excess until 1 March 2022. £0
As you have paid your excess in full you will not have to pay an excess
towards any further claims you make until 1 March 2022 when your excess
will then return to the full amount of £100
Example of how a co-insurance works: this is an example only and assumes that all costs
are eligible treatment costs and:
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a co-insurance of 20% up to a maximum of £500 each year
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an out-patient benefit limit of £500 a year.
Example Excess
Out-patient benefit limit for the year £500
You incur costs for out-patient physiotherapy £250
We pay your therapist 80% £200
We notify you of the 20% co-insurance payment you pay direct to £50
your therapist
Your remaining out-patient benefit limit for the rest of the year £250
Your remaining maximum co-insurance for the rest of the year £450
Claiming Page 23Benefits
This section explains the type of charges we pay for eligible treatment subject to your
medical condition, the type of treatment you need and your chosen medical practitioners
and/or treatment facility all being eligible under your benefits.
Notes on benefits
The following notes apply equally to all the benefits and should be read together with
those benefits.
Restrictions and/or limitations to benefits
Your cover may be limited or restricted through one or more of the following:
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If you are a moratorium member
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If you are an underwritten member: please note, if you and/or your dependants are an
underwritten member, it is important that you complete and send us the application
form for you and/or for your dependants if the special conditions section of your
membership certificate states that we require you to do so. Until you have completed
this we will not be able to confirm exactly what your policy covers you and/or your
dependants for, meaning your claims might take longer for us to process or you might
not be eligible to claim for treatment you need
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Benefit limits: these are limits on the amounts we will pay and/or restrictions on the
cover you have under your benefits. Your membership certificate shows the benefit
limits and/or restrictions that apply to your benefits
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Excess or co-insurance: these are explained in rule E in the section ‘Claiming’. Your
membership certificate shows if an excess or co-insurance applies to your benefits.
If one does apply, your benefit limits shown on your membership certificate will be
subject to your excess or co-insurance
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Overall annual maximum benefit: this is a limit on the overall amount we will pay
under your benefits each year. Your membership certificate shows if an overall annual
maximum benefit applies to your benefits. If one does apply, your benefit limits shown
on your membership certificate will be subject to your overall annual maximum
benefit. Your excess and/or co-insurance will count towards your overall annual
maximum benefit
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If the Open Referral service applies to your benefits: check within the ‘Group Details’
section of your membership certificate to see if the Open Referral service applies to
your benefits. If it does, you must be referred for treatment either:
– by our Direct Access service (if you have cover for it), or
– by obtaining an open referral from a GP. You should then call us to
pre-authorise your treatment and we will help you find:
– a fee-assured consultant in our list of Open Referral Network consultants that
applies to your benefits, or
– a recognised practitioner in your local area.
Page 24 BenefitsFailure to call us to obtain pre-authorisation for your treatment means that you will
be responsible for paying for all such treatment if we would not have pre-authorised
it. The Open Referral service does not apply to referral for a child. For full details of
the Open Referral service please see ‘A step-by-step guide to making a claim’ in the
‘Claiming’ section of this membership guide.
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Exclusions that apply to your cover: the general exclusions are set out in the section
‘What is not covered’. Some exclusions also apply in this section and there may also
be exclusions on your membership certificate.
Being referred for treatment
Your consultation or treatment must follow an initial referral by:
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our Direct Access service, if you have cover for it. For details about cover for Direct
Access and how it works see the section ‘Direct Access service’
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a GP (including via a digital GP service), or
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another healthcare practitioner. The situations in which we will accept such a referral
are set out on bupa.co.uk/referrals
Direct Access service
Important: You are only covered for Direct Access when the ‘Further details’ section on
your membership certificate says it is covered and if it is, it will also say which medical
conditions Direct Access is available for. If you do not have cover for any Direct Access
you should ignore all references to Direct Access in this membership guide.
If you do have cover for our Direct Access service, it can help provide a fast and
convenient way for you to access eligible treatment for certain medical conditions
without the need for a GP referral. Age limits apply to who can use the service. Further
details about the Direct Access service, including the age limits that apply, can be found
on bupa.co.uk/direct-access or you can call us.
Please note:
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if you are an underwritten member, before a referral for treatment can be made
through our Direct Access service you may need to provide us with certain
information to establish that your condition is not a pre-existing condition (please see
‘B2 Providing us with information’ in the ‘Claiming’ section of this guide for full details)
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if you are a moratorium member, before using the Direct Access service you will
need to follow the standard process for claiming to establish that your condition is
not a moratorium condition (please see ‘If you are moratorium member’ under A1 in
the Claiming section of this guide for full details)
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if monetary limits apply to your benefits for out-patient consultations and therapies
and you have used all the out-patient benefits available to you for the year you can
still use the Direct Access service but any out-patient consultations or therapies you
are referred for would not be covered under your benefits.
The charge for any telephone assessments required as part of our Direct Access process
will not:
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erode your out-patient benefit limit if you have one, nor
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be subject to your excess or co-insurance if they apply to your cover.
Benefits Page 25However, if you have an overall annual maximum benefit, the charge will count towards
your overall annual maximum benefit.
If you go on to receive and claim for eligible treatment following referral by our Direct
Access service, that treatment will be treated as a normal claim under your cover.
Bupa recognised medical practitioners and recognised facilities
Your cover for eligible treatment costs depends on you using certain Bupa recognised
medical and other health practitioners and recognised facilities.
Please note:
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the medical practitioners, other healthcare professionals and recognised facilities you
use can affect the level of benefits we pay you
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certain medical practitioners, other healthcare professionals and recognised facilities
that we recognise may only be recognised by us for certain types of treatment or
treating certain medical conditions or certain levels of benefits
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the medical practitioners, other healthcare professionals and recognised facilities
that we recognise and the type of medical condition and/or type of treatment and/or
level of benefit that we recognise them for will change from time to time.
Your treatment costs are only covered when:
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if the Open Referral service does not apply to your benefits: the person who has
overall responsibility for your treatment is a consultant. If the person who has overall
responsibility for your treatment is not a consultant then none of your treatment
costs are covered – the only exception to this is where a GP or our Direct Access
service refers you for out-patient treatment by a therapist, complementary medicine
practitioner or mental health and wellbeing therapist
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if the Open Referral service does apply to your benefits: the person who has overall
responsibility for your treatment is a consultant in our list of Open Referral Network
consultants that applies to your benefits. If the person who has overall responsibility
for your treatment is not in our list of Open Referral Network consultants that
applies to your benefits then none of your treatment costs are covered – the only
exception to this is where a GP or our Direct Access service refers you for out-patient
treatment by a therapist, complementary medicine practitioner or mental health
and wellbeing therapist
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the medical practitioner or other healthcare professional and the recognised facility
are recognised by us for treating the medical condition you have and for providing
the type of treatment you need.
Changes to lists
Where we refer to a list that we can change, it will be for one or more of the
following reasons:
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where we are required to by any industry code, law or regulation
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where a contract ends or is amended by a third party for any reason
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where we elect to terminate or amend a contract, for example because of quality
concerns or changes in the provision of facilities and/or specialist services
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where the geographic balance of the service we provide is to be maintained
Page 26 BenefitsYou can also read
